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<title>Claimants Statement HTML 20130514</title>
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<meta name="author" content="Wilile Visagie">
<meta name="description" content="Claimants statement Form for HTML Export Modified 14052013, by Willie Visagie. Corrections and Changes as per Updated Bug List 08-05-2013.">
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<meta name="date" content="2013-05-14T17:06:51+17:06">
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<div class='div_text1'><div align='right'><span style='font: bold normal 8pt Arial;color:#000000;text-decoration: none'>CLAIMANT’S STATEMENT <br /></span></div><div align='right'><span style=''>(TO BE COMPLETED BY FAMILY MEMBER) <br /></span></div><div align='right'><span style=''> <br /></span></div></div>
<div class='div_line_18'></div>
<div class='div_text2'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>SECTION A - DETAILS OF THE PERSON SUBMITTING THIS CLAIM <br /></span></div>
<p /><label for='f22' class='clslbl'>Claimant Salutation</label>
<input type=TEXT value='' class='f22' id='f22' name='ADTitle' tabindex=1 title="Claimant Salutation" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 1);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,12);' onKeyDown = 'maxl(this,12);return EP_OKD(this ,event);'>
<p /><label for='f23' class='clslbl'>Surname of Claimant</label>
<input type=TEXT value='' class='f23' id='f23' name='Surname' tabindex=2 title="Surname of Claimant" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,20);' onKeyDown = 'maxl(this,20);return EP_OKD(this ,event);'>
<div class='div_text4'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Title <br /></span></div>
<div class='div_text5'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Surname <br /></span></div>
<p /><label for='f28' class='clslbl'>First name(s)  of Claimant</label>
<input type=TEXT value='' class='f28' id='f28' name='First_Names' tabindex=3 title="First name(s)&nbsp;&nbsp;of Claimant" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text6'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>First name(s) <br /></span></div>
<p /><label for='f33' class='clslbl'> Work Phone number of Claimant</label>
<input type=TEXT value='' class='f33' id='f33' name='Work_Number' tabindex=4 title=" Work Phone number of Claimant" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,10);' onKeyDown = 'maxl(this,10);return EP_OKD(this ,event);'>
<p /><label for='f34' class='clslbl'> Cell Phone number of Claimant</label>
<input type=TEXT value='' class='f34' id='f34' name='Cell_Number' tabindex=5 title=" Cell Phone number of Claimant" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,10);' onKeyDown = 'maxl(this,10);return EP_OKD(this ,event);'>
<p /><label for='f35' class='clslbl'> Home Phone number of Claimant</label>
<input type=TEXT value='' class='f35' id='f35' name='Home_Number' tabindex=6 title=" Home Phone number of Claimant" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,10);' onKeyDown = 'maxl(this,10);return EP_OKD(this ,event);'>
<div class='div_text7'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Tel (w) <br /></span></div>
<div class='div_text8'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Cell <br /></span></div>
<div class='div_text9'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Tel (h) <br /></span></div>
<p /><label for='f41' class='clslbl'>Address Line 1 of Claimant</label>
<input type=TEXT value='' class='f41' id='f41' name='Address_Line_1' tabindex=7 title="Address Line 1 of Claimant" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text11'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Line 1 <br /></span></div>
<div class='div_text15'><div align='center'><span style='font: normal normal 8pt Arial;color:#000000;text-decoration: none'>Postal <br /></span></div><div align='center'><span style=''>address <br /></span></div></div>
<p /><label for='f46' class='clslbl'>Suburb of Claimant</label>
<input type=TEXT value='' class='f46' id='f46' name='Suburb' tabindex=8 title="Suburb of Claimant" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 1);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text12'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Suburb <br /></span></div>
<p /><label for='f49' class='clslbl'>Town of Claimant</label>
<input type=TEXT value='' class='f49' id='f49' name='Town' tabindex=9 title="Town of Claimant" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 1);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text13'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Town <br /></span></div>
<p /><label for='f52' class='clslbl'>Postal Code of Claimant</label>
<input type=TEXT value='' class='f52' id='f52' name='Code' tabindex=10 title="Postal Code of Claimant" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_text14'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Code <br /></span></div>
<div class='f54_box'></div><p /><label for='f54' class='clslbl'>Capacity in which you are submitting the claim - 1</label>
<input type=RADIO class='f54' id='f54' name='ADCap' value='1' tabindex=11 title="Capacity in which you are submitting the claim - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f55_box'></div><p /><label for='f55' class='clslbl'>Capacity in which you are submitting the claim - 2</label>
<input type=RADIO class='f55' id='f55' name='ADCap' value='2' tabindex=11 title="Capacity in which you are submitting the claim - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f56_box'></div><p /><label for='f56' class='clslbl'>Capacity in which you are submitting the claim - 3</label>
<input type=RADIO class='f56' id='f56' name='ADCap' value='3' tabindex=11 title="Capacity in which you are submitting the claim - 3" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<p /><label for='f57' class='clslbl'> Other Capacity</label>
<textarea class='f57' id='f57' name='ADCap_1' spellcheck='false' tabindex=12 title=" Other Capacity" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<div class='div_text48'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Capacity in which you are submitting the claim: <br /></span></div>
<div class='div_text49'><span style='font: 6pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Beneficiary <br /></span></div>
<div class='div_text50'><span style='font: 6pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Executor <br /></span></div>
<div class='div_text51'><span style='font: 6pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Other <br /></span></div>
<p /><label for='f63' class='clslbl'>Claimant Email address</label>
<textarea class='f63' id='f63' name='Email_Address' spellcheck='false' tabindex=13 title="Claimant Email address" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 1);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<div class='div_text10'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Email address <br /></span></div>
<p /><label for='f70' class='clslbl'>Relationship of claimant to the deceased</label>
<textarea class='f70' id='f70' name='ADRelationship' spellcheck='false' tabindex=14 title="Relationship of claimant to the deceased" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<div class='div_text16'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Relationship of claimant to the deceased <br /></span></div>
<div class='div_line_74'></div>
<div class='div_text17'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>SECTION B - DECEASED&#39;S DETAILS <br /></span></div>
<p /><label for='f77' class='clslbl'>Deceased Salutation</label>
<input type=TEXT value='' class='f77' id='f77' name='ADTitle_2' tabindex=15 title="Deceased Salutation" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 1);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,12);' onKeyDown = 'maxl(this,12);return EP_OKD(this ,event);'>
<p /><label for='f78' class='clslbl'>Deceased Surname</label>
<input type=TEXT value='' class='f78' id='f78' name='ADSurname_2' tabindex=16 title="Deceased Surname" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,20);' onKeyDown = 'maxl(this,20);return EP_OKD(this ,event);'>
<div class='div_text18'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Title <br /></span></div>
<div class='div_text19'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Surname <br /></span></div>
<p /><label for='f86' class='clslbl'>Deceased First name</label>
<input type=TEXT value='' class='f86' id='f86' name='ADFirstNames_2' tabindex=17 title="Deceased First name" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text20'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>First name(s) <br /></span></div>
<p /><label for='f91' class='clslbl'>Deceased ID Number</label>
<input type=TEXT value='' class='f91' id='f91' name='IDNumber' tabindex=18 title="Deceased ID Number" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,13);' onKeyDown = 'maxl(this,13);return EP_OKD(this ,event);'>
<p /><label for='f92' class='clslbl'>Deceased last occupation</label>
<textarea class='f92' id='f92' name='ADLastoccupation' spellcheck='false' tabindex=19 title="Deceased last occupation" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<div class='div_text21'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>ID number <br /></span></div>
<div class='div_text22'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Last occupation <br /></span></div>
<p /><label for='f96' class='clslbl'>Deceased last residential address Line 1</label>
<input type=TEXT value='' class='f96' id='f96' name='ADPALine1_2' tabindex=20 title="Deceased last residential address Line 1" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text23'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Line 1 <br /></span></div>
<div class='div_text24'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Last residential address <br /></span></div>
<p /><label for='f101' class='clslbl'>Deceased last residential address Suburb</label>
<input type=TEXT value='' class='f101' id='f101' name='ADPASuburb_2' tabindex=21 title="Deceased last residential address Suburb" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 1);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text25'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Suburb <br /></span></div>
<p /><label for='f104' class='clslbl'>Deceased last residential address Town</label>
<input type=TEXT value='' class='f104' id='f104' name='ADPATown_2' tabindex=22 title="Deceased last residential address Town" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text26'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Town <br /></span></div>
<p /><label for='f108' class='clslbl'>Deceased last residential address Code</label>
<input type=TEXT value='' class='f108' id='f108' name='ADPACode_2' tabindex=23 title="Deceased last residential address Code" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_text27'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Code <br /></span></div>
<div class='div_text28'><div align='left'><span style='font: bold normal 8pt Arial;color:#000000;text-decoration: none'>Number of each policy with Nedgroup Life under which you are claiming <br /></span></div><div align='left'><span style=''> <br /></span></div></div>
<p /><label for='f113' class='clslbl'>Number of each policy with Nedgroup Life under which you are claiming 1</label>
<input type=TEXT value='' class='f113' id='f113' name='PolicyNumber' tabindex=24 title="Number of each policy with Nedgroup Life under which you are claiming 1" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,16);' onKeyDown = 'maxl(this,16);return EP_OKD(this ,event);'>
<p /><label for='f116' class='clslbl'>Number of each policy with Nedgroup Life under which you are claiming 2</label>
<input type=TEXT value='' class='f116' id='f116' name='PolicyNumber_2' tabindex=25 title="Number of each policy with Nedgroup Life under which you are claiming 2" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,16);' onKeyDown = 'maxl(this,16);return EP_OKD(this ,event);'>
<p /><label for='f119' class='clslbl'>Number of each policy with Nedgroup Life under which you are claiming 3</label>
<input type=TEXT value='' class='f119' id='f119' name='PolicyNumber_3' tabindex=26 title="Number of each policy with Nedgroup Life under which you are claiming 3" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,16);' onKeyDown = 'maxl(this,16);return EP_OKD(this ,event);'>
<div class='div_rect_124'></div>
<div class='div_line_125'></div>
<div class='div_line_126'></div>
<div class='div_line_127'></div>
<div class='div_text29'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Name of company <br /></span></div>
<div class='div_text30'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Policy/Account number <br /></span></div>
<div class='div_text31'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Amount <br /></span></div>
<div class='div_text32'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Date issued <br /></span></div>
<div class='div_text60'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) <br /></span></div>
<div class='div_line_139'></div>
<p /><label for='f140' class='clslbl'>Company of each policy with Nedgroup Life under which you are claiming 1</label>
<textarea class='f140' id='f140' name='CoName' spellcheck='false' tabindex=27 title="Company of each policy with Nedgroup Life under which you are claiming 1" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f141' class='clslbl'>OtherPolno</label>
<textarea class='f141' id='f141' name='OtherPolno' spellcheck='false' tabindex=28 title="OtherPolno" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f142' class='clslbl'>Amt</label>
<input type=TEXT value='' class='f142' id='f142' name='Amt' tabindex=29 title="Amt" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this ,event);'>
<p /><label for='f143' class='clslbl'>Date of Issue</label>
<input type=TEXT value='' class='f143' id='f143' name='Date_Policy_Issued_1' tabindex=30 title="Date of Issue" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<p /><label for='f148' class='clslbl'>Company of each policy with Nedgroup Life under which you are claiming 2</label>
<textarea class='f148' id='f148' name='CoName_2' spellcheck='false' tabindex=31 title="Company of each policy with Nedgroup Life under which you are claiming 2" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f149' class='clslbl'>OtherPolno_2</label>
<textarea class='f149' id='f149' name='OtherPolno_2' spellcheck='false' tabindex=32 title="OtherPolno_2" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f150' class='clslbl'>Amt_2</label>
<input type=TEXT value='' class='f150' id='f150' name='Amt_2' tabindex=33 title="Amt_2" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this ,event);'>
<p /><label for='f151' class='clslbl'>Date of Issue</label>
<input type=TEXT value='' class='f151' id='f151' name='Date_Policy_Issued_2' tabindex=34 title="Date of Issue" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<p /><label for='f157' class='clslbl'>Company of each policy with Nedgroup Life under which you are claiming 3</label>
<textarea class='f157' id='f157' name='CoName_3' spellcheck='false' tabindex=35 title="Company of each policy with Nedgroup Life under which you are claiming 3" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f158' class='clslbl'>OtherPolno_3</label>
<textarea class='f158' id='f158' name='OtherPolno_3' spellcheck='false' tabindex=36 title="OtherPolno_3" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f159' class='clslbl'>Amt_3</label>
<input type=TEXT value='' class='f159' id='f159' name='Amt_3' tabindex=37 title="Amt_3" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this ,event);'>
<p /><label for='f160' class='clslbl'>Date of Issue</label>
<input type=TEXT value='' class='f160' id='f160' name='Date_Policy_Issued_3' tabindex=38 title="Date of Issue" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<p /><label for='f166' class='clslbl'>Date of Death</label>
<input type=TEXT value='' class='f166' id='f166' name='Date_of_event' tabindex=39 title="Date of Death" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<p /><label for='f167' class='clslbl'>Time of Death</label>
<input type=TEXT value='' class='f167' id='f167' name='time_of_event' tabindex=40 title="Time of Death" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,4);' onKeyDown = 'maxl(this,4);return EP_OKD(this ,event);'>
<div class='div_text55'><span style='font: 10pt "Courier New";color:#000000;text-decoration:none;'>- <br /></span></div>
<div class='div_text56'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Date and time of death <br /></span></div>
<div class='div_text57'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy - hh mm) <br /></span></div>
<p /><label for='f173' class='clslbl'>Place of Death</label>
<textarea class='f173' id='f173' name='Place_of_Death' spellcheck='false' tabindex=41 title="Place of Death" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,25);' onKeyDown = 'maxl(this,25);return EP_OKD(this,event);' ></textarea>
<div class='div_text3'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Place of death <br /></span></div>
<p /><label for='f175' class='clslbl'>Postal address of hospital Line 1</label>
<input type=TEXT value='' class='f175' id='f175' name='Hospital_Address_Line_1' tabindex=42 title="Postal address of hospital Line 1" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text33'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Line 1 <br /></span></div>
<div class='div_text34'><div align='center'><span style='font: normal normal 6pt Arial;color:#000000;text-decoration: none'>Postal address of hospital <br /></span></div><div align='center'><span style=''>(if applicable): <br /></span></div></div>
<p /><label for='f178' class='clslbl'>Postal address of hospital Suburb</label>
<input type=TEXT value='' class='f178' id='f178' name='Hospital_Address_Suburb' tabindex=43 title="Postal address of hospital Suburb" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 1);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text35'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Suburb <br /></span></div>
<p /><label for='f180' class='clslbl'>Postal address of hospital Town</label>
<input type=TEXT value='' class='f180' id='f180' name='Hospital_Address_Town' tabindex=44 title="Postal address of hospital Town" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 1);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text36'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Town <br /></span></div>
<p /><label for='f182' class='clslbl'>Postal address of hospital postal code</label>
<input type=TEXT value='' class='f182' id='f182' name='Hospital_Address_Code' tabindex=45 title="Postal address of hospital postal code" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_text37'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Code <br /></span></div>
<div class='f184_box'></div><p /><label for='f184' class='clslbl'>Cause of Death - Natural</label>
<input type=RADIO class='f184' id='f184' name='Nature_of_incident' value='Natural' tabindex=46 title="Cause of Death - Natural" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f185_box'></div><p /><label for='f185' class='clslbl'>Cause of Death - Unnatural</label>
<input type=RADIO class='f185' id='f185' name='Nature_of_incident' value='Unnatural' tabindex=46 title="Cause of Death - Unnatural" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text41'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Please describe the actual cause of death <br /></span></div>
<div class='div_text38'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Cause of death <br /></span></div>
<div class='div_text39'><span style='font: 6pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Natural <br /></span></div>
<div class='div_text40'><span style='font: 6pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Unnatural <br /></span></div>
<p /><label for='f190' class='clslbl'> Description of actual cause of Death</label>
<textarea class='f190' id='f190' name='ADCap_1_2' spellcheck='false' tabindex=47 title=" Description of actual cause of Death" onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f191' class='clslbl'>When did the health of the deceased first begin to be affected?</label>
<input type=TEXT value='' class='f191' id='f191' name='Date_HA' tabindex=48 title="When did the health of the deceased first begin to be affected?" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_text53'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>When did the health of the deceased first begin to be affected? <br /></span></div>
<div class='div_text58'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) <br /></span></div>
<p /><label for='f194' class='clslbl'>When did the deceased first consult a doctor for his/her illness?</label>
<input type=TEXT value='' class='f194' id='f194' name='Date_CD' tabindex=49 title="When did the deceased first consult a doctor for his/her illness?" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_text54'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>When did the deceased first consult a doctor for his/her illness? <br /></span></div>
<div class='div_text59'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) <br /></span></div>
<div class='div_text42'>  <span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Name and address of </span><span style='font: 8pt "Arial";color:#000000;text-decoration:underline;'>every  </span><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>doctor who attended the deceased during his/her last illness </span><span style='font: 8pt "Arial";color:#000000;text-decoration:underline;'>and  </span><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>during the five years preceding his/her death <br /></span></div>
<div class='div_rect_198'></div>
<div class='div_line_199'></div>
<div class='div_line_200'></div>
<div class='div_text43'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Name and address <br /></span></div>
<div class='div_text44'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Disease or condition <br /></span></div>
<div class='div_text45'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Date of attendance (ddmmyyyy) <br /></span></div>
<div class='div_line_204'></div>
<p /><label for='f205' class='clslbl'>Name and address of every doctor who attended the deceased during his/her last illness and during the five years preceding his/her death</label>
<textarea class='f205' id='f205' name='CoName_4' spellcheck='false' tabindex=50 title="Name and address of every doctor who attended the deceased during his/her last illness and during the five years preceding his/her death" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f206' class='clslbl'>Disease or condition</label>
<textarea class='f206' id='f206' name='Amt_4' spellcheck='false' tabindex=51 title="Disease or condition" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f207' class='clslbl'> Date of attendance</label>
<input type=TEXT value='' class='f207' id='f207' name='DOA_1' tabindex=52 title=" Date of attendance" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<p /><label for='f208' class='clslbl'>Name and address of every doctor who attended the deceased during his/her last illness and during the five years preceding his/her death</label>
<textarea class='f208' id='f208' name='CoName_2_2' spellcheck='false' tabindex=53 title="Name and address of every doctor who attended the deceased during his/her last illness and during the five years preceding his/her death" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f209' class='clslbl'>Disease or condition</label>
<textarea class='f209' id='f209' name='Amt_2_2' spellcheck='false' tabindex=54 title="Disease or condition" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f210' class='clslbl'> Date of attendance</label>
<input type=TEXT value='' class='f210' id='f210' name='DOA_2' tabindex=55 title=" Date of attendance" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<p /><label for='f211' class='clslbl'>Name and address of every doctor who attended the deceased during his/her last illness and during the five years preceding his/her death</label>
<textarea class='f211' id='f211' name='CoName_3_2' spellcheck='false' tabindex=56 title="Name and address of every doctor who attended the deceased during his/her last illness and during the five years preceding his/her death" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f212' class='clslbl'>Disease or condition</label>
<textarea class='f212' id='f212' name='Amt_3_2' spellcheck='false' tabindex=57 title="Disease or condition" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f213' class='clslbl'>Date of attendance</label>
<input type=TEXT value='' class='f213' id='f213' name='DOA_3' tabindex=58 title="Date of attendance" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_line_214'></div>
<div class='div_text47'><div align='left'><span style='font: normal normal 7pt Arial;color:#000000;text-decoration: none'>Nedgroup Life Assurance Company Limited .Reg No 1993/001022/06 <br /></span></div><div align='left'><span style=''>1st Floor, Ridgeside Campus, 2 Ncondo Drive, Umhlanga Rocks, 4320 ; PO Box 149175, East End, 4018. <br /></span></div><div align='left'><span style=''>Tel 0860 263 543 Fax 0860 065 437 Website www.nedgrouplife.co.za. <br /></span></div></div>
<div class='div_line_218'></div>
<div class='div_text52'><span style='font: 7pt "Arial";color:#000000;text-decoration:none;'>We support resolution for unresolved disputes via the Ombudsman for Long-term insurance. We are an authorised financial services provider (licence number 40915).&nbsp;&nbsp; We are a registered credit provider in terms of the National Credit Act (NCR Reg No NCRCP61) . <br /></span></div>
<div class='div_line_222'></div>
<div class='div_text46'><span style='font: 7pt "Arial";color:#000000;text-decoration:none;'>Page 1 of 2 <br /></span></div>
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<div id='page2' class='page2' ontouchstart="touchStart(event,'page2');" ontouchend=" touchEnd(event);" ontouchmove="touchMove(event);" ontouchcancel="touchCancel(event);"></div>
<div class='f10_box'></div><p /><label for='f10' class='clslbl'>Was a Funeral Parlour used? - Yes</label>
<input type=RADIO class='f10' id='f10' name='UseOfFP' value='Yes' tabindex=60 title="Was a Funeral Parlour used? - Yes" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f11_box'></div><p /><label for='f11' class='clslbl'>Was a Funeral Parlour used? - No</label>
<input type=RADIO class='f11' id='f11' name='UseOfFP' value='No' tabindex=60 title="Was a Funeral Parlour used? - No" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<p /><label for='f12' class='clslbl'>Date of Funeral</label>
<input type=TEXT value='' class='f12' id='f12' name='DOF' tabindex=59 title="Date of Funeral" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_text74'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Yes <br /></span></div>
<div class='div_text75'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>No <br /></span></div>
<div class='div_text73'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Was a Funeral Parlour used? <br /></span></div>
<div class='div_text94'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) <br /></span></div>
<div class='div_text93'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Date of funeral <br /></span></div>
<p /><label for='f20' class='clslbl'> Name of Funeral parlour</label>
<input type=TEXT value='' class='f20' id='f20' name='Funeral_Palour_Name' tabindex=61 title=" Name of Funeral parlour" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,28);' onKeyDown = 'maxl(this,28);return EP_OKD(this ,event);'>
<div class='div_text62'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Name of funeral parlour <br /></span></div>
<p /><label for='f26' class='clslbl'> Tel of Funeral parlour</label>
<input type=TEXT value='' class='f26' id='f26' name='FP_Tel' tabindex=62 title=" Tel of Funeral parlour" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,10);' onKeyDown = 'maxl(this,10);return EP_OKD(this ,event);'>
<div class='div_text63'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Tel no of funeral parlour <br /></span></div>
<p /><label for='f29' class='clslbl'>Name of deceased’s employer at date of death</label>
<input type=TEXT value='' class='f29' id='f29' name='ADTitle_3' tabindex=63 title="Name of deceased’s employer at date of death" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,24);' onKeyDown = 'maxl(this,24);return EP_OKD(this ,event);'>
<div class='div_text61'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Name of deceased’s employer at date of death <br /></span></div>
<p /><label for='f32' class='clslbl'>Name of deceased’s medical aid at date of death</label>
<input type=TEXT value='' class='f32' id='f32' name='ADTitle_3_2' tabindex=64 title="Name of deceased’s medical aid at date of death" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,24);' onKeyDown = 'maxl(this,24);return EP_OKD(this ,event);'>
<div class='div_text65'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Name of deceased’s medical aid at date of death <br /></span></div>
<p /><label for='f40' class='clslbl'>Medical aid membership number</label>
<input type=TEXT value='' class='f40' id='f40' name='MedicalAidNumber' tabindex=65 title="Medical aid membership number" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,10);' onKeyDown = 'maxl(this,10);return EP_OKD(this ,event);'>
<div class='div_text66'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Medical aid membership number <br /></span></div>
<div class='div_text64'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Have you any knowledge of any cession or other lien on the contract? If so, please give details. <br /></span></div>
<p /><label for='f48' class='clslbl'>Have you any knowledge of any cession or other lien on the contract? If so, please give details.</label>
<textarea class='f48' id='f48' name='ADRelationship_2' spellcheck='false' tabindex=66 title="Have you any knowledge of any cession or other lien on the contract? If so, please give details." onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<div class='div_text72'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Have you or the deceased ever been insolvent or made any assignment for the benefit of creditors or are any such proceedings pending or contemplated? If so, please give full details. <br /></span></div>
<p /><label for='f62' class='clslbl'>Have you or the deceased ever been insolvent or made any assignment for the benefit of creditors or are any such proceedings pending or contemplated? If so, please give full details.</label>
<textarea class='f62' id='f62' name='ADEmailAddress_2_2' spellcheck='false' tabindex=67 title="Have you or the deceased ever been insolvent or made any assignment for the benefit of creditors or are any such proceedings pending or contemplated? If so, please give full details." onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<div class='f65_box'></div><p /><label for='f65' class='clslbl'>Was the estate of the deceased insolvent at the time of death? - 1</label>
<input type=RADIO class='f65' id='f65' name='ADCap_2' value='1' tabindex=68 title="Was the estate of the deceased insolvent at the time of death? - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f66_box'></div><p /><label for='f66' class='clslbl'>Was the estate of the deceased insolvent at the time of death? - 2</label>
<input type=RADIO class='f66' id='f66' name='ADCap_2' value='2' tabindex=68 title="Was the estate of the deceased insolvent at the time of death? - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text67'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Was the estate of the deceased insolvent at the time of death? <br /></span></div>
<div class='div_text68'><span style='font: 6pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Yes <br /></span></div>
<div class='div_text69'><span style='font: 6pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>No <br /></span></div>
<div class='div_line_72'></div>
<div class='div_text95'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>SECTION D - RELEASE AND DISCHARGE – FOR POLICIES NOT CEDED <br /></span></div>
<div class='div_text96'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>I/We the undersigned declare and warrant to the best of my/our knowledge and belief that the estate of the late <br /></span></div>
<p /><label for='f81' class='clslbl'>decesed_name</label>
<textarea class='f81' id='f81' name='decesed_name' spellcheck='false' tabindex=69 title="decesed_name" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f82' class='clslbl'>DOD</label>
<input type=TEXT value='' class='f82' id='f82' name='DOD' tabindex=70 title="DOD" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_text97'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) was not insolvent. <br /></span></div>
<div class='div_text101'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(&#39;the deceased&#39;), who <br /></span></div>
<div class='div_text104'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>died on <br /></span></div>
<p /><label for='f88' class='clslbl'>ADPACode_3_2</label>
<input type=TEXT value='' class='f88' id='f88' name='ADPACode_3_2' tabindex=71 title="ADPACode_3_2" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 1);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,10);' onKeyDown = 'maxl(this,10);return EP_OKD(this ,event);'>
<div class='div_text103'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>R <br /></span></div>
<div class='div_text102'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>I/We acknowledge and agree that upon payment by Nedgroup Life to me/us of the sum assured <br /></span></div>
<div class='div_text98'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Nedgroup Life is and will be released and discharged from all or any other obligations arising from policy number <br /></span></div>
<p /><label for='f98' class='clslbl'>PolicyNumber_3_2</label>
<input type=TEXT value='' class='f98' id='f98' name='PolicyNumber_3_2' tabindex=72 title="PolicyNumber_3_2" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,16);' onKeyDown = 'maxl(this,16);return EP_OKD(this ,event);'>
<div class='div_text99'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>issued by Nedgroup Life on the life of the deceased. <br /></span></div>
<div class='div_text100'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>I/We the undersigned hereby instruct Nedgroup Life to pay the proceeds of the policy into my/our bank account(s) as follows: <br /></span></div>
<div class='div_line_105'></div>
<div class='div_text76'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:underline;'>Beneficiary <br /></span></div>
<p /><label for='f110' class='clslbl'>Beneficiary 1 Surname</label>
<input type=TEXT value='' class='f110' id='f110' name='ADSurname_3' tabindex=73 title="Beneficiary 1 Surname" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text78'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Surname <br /></span></div>
<p /><label for='f114' class='clslbl'>Beneficiary 1 Firstname</label>
<input type=TEXT value='' class='f114' id='f114' name='ADFirstNames_4' tabindex=74 title="Beneficiary 1 Firstname" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text79'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>First name(s) <br /></span></div>
<p /><label for='f117' class='clslbl'>Beneficiary 1 ID Number</label>
<input type=TEXT value='' class='f117' id='f117' name='BeneficiaryIDno_1' tabindex=75 title="Beneficiary 1 ID Number" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,13);' onKeyDown = 'maxl(this,13);return EP_OKD(this ,event);'>
<div class='div_text77'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>ID no <br /></span></div>
<p /><label for='f120' class='clslbl'>Beneficiary Income Tax Office</label>
<input type=TEXT value='' class='f120' id='f120' name='TDTaxOffice' tabindex=76 title="Beneficiary Income Tax Office" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,15);' onKeyDown = 'maxl(this,15);return EP_OKD(this ,event);'>
<p /><label for='f121' class='clslbl'>Beneficiary 1 Income Tax Number</label>
<input type=TEXT value='' class='f121' id='f121' name='TDTaxNumber' tabindex=77 title="Beneficiary 1 Income Tax Number" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,13);' onKeyDown = 'maxl(this,13);return EP_OKD(this ,event);'>
<div class='div_text83'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Income tax office <br /></span></div>
<div class='div_text84'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Income tax number <br /></span></div>
<p /><label for='f133' class='clslbl'> Beneficiary 1 Work Number</label>
<input type=TEXT value='' class='f133' id='f133' name='ADTelWork_3' tabindex=78 title=" Beneficiary 1 Work Number" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,10);' onKeyDown = 'maxl(this,10);return EP_OKD(this ,event);'>
<p /><label for='f134' class='clslbl'> Beneficiary 1 Cell Number</label>
<input type=TEXT value='' class='f134' id='f134' name='ADCell_2' tabindex=79 title=" Beneficiary 1 Cell Number" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,10);' onKeyDown = 'maxl(this,10);return EP_OKD(this ,event);'>
<p /><label for='f135' class='clslbl'> Beneficiary 1 Home Number</label>
<input type=TEXT value='' class='f135' id='f135' name='ADTelHome_2' tabindex=80 title=" Beneficiary 1 Home Number" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,10);' onKeyDown = 'maxl(this,10);return EP_OKD(this ,event);'>
<div class='div_text80'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Tel (w) <br /></span></div>
<div class='div_text81'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Cell <br /></span></div>
<div class='div_text82'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Tel (h) <br /></span></div>
<p /><label for='f144' class='clslbl'>Beneficiary 1 Bank Name</label>
<textarea class='f144' id='f144' name='DDBank' spellcheck='false' tabindex=81 title="Beneficiary 1 Bank Name" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 1);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<p /><label for='f145' class='clslbl'>Beneficiary 1 Branch name</label>
<textarea class='f145' id='f145' name='DDBranchName' spellcheck='false' tabindex=82 title="Beneficiary 1 Branch name" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 1);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<div class='div_text85'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Bank <br /></span></div>
<div class='div_text92'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Branch <br /></span></div>
<div class='f152_box'></div><p /><label for='f152' class='clslbl'>Beneficiary 1 account Type - 1</label>
<input type=RADIO class='f152' id='f152' name='DDTypeOfAccount' value='1' tabindex=83 title="Beneficiary 1 account Type - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f153_box'></div><p /><label for='f153' class='clslbl'>Beneficiary 1 account Type - 2</label>
<input type=RADIO class='f153' id='f153' name='DDTypeOfAccount' value='2' tabindex=83 title="Beneficiary 1 account Type - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f154_box'></div><p /><label for='f154' class='clslbl'>Beneficiary 1 account Type - 3</label>
<input type=RADIO class='f154' id='f154' name='DDTypeOfAccount' value='3' tabindex=83 title="Beneficiary 1 account Type - 3" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<p /><label for='f155' class='clslbl'>Beneficiary 1 Branch Code</label>
<input type=TEXT value='' class='f155' id='f155' name='DDBranchCode' tabindex=84 title="Beneficiary 1 Branch Code" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,6);' onKeyDown = 'maxl(this,6);return EP_OKD(this ,event);'>
<p /><label for='f156' class='clslbl'> Beneficiary Bank code</label>
<textarea class='f156' id='f156' name='DDBankCode' spellcheck='false' tabindex=85 title=" Beneficiary Bank code" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,30);' onKeyDown = 'maxl(this,30);return EP_OKD(this,event);' ></textarea>
<div class='div_text87'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Current <br /></span></div>
<div class='div_text88'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Savings <br /></span></div>
<div class='div_text89'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Transmission <br /></span></div>
<div class='div_text90'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Branch code <br /></span></div>
<div class='div_text86'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Type of account <br /></span></div>
<p /><label for='f168' class='clslbl'>Beneficiary 1 Account Number</label>
<input type=TEXT value='' class='f168' id='f168' name='DDAccountNumber' tabindex=86 title="Beneficiary 1 Account Number" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,16);' onKeyDown = 'maxl(this,16);return EP_OKD(this ,event);'>
<div class='div_text91'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Account number <br /></span></div>
<div class='div_line_216'></div>
<div class='div_text71'><div align='left'><span style='font: normal normal 7pt Arial;color:#000000;text-decoration: none'>Nedgroup Life Assurance Company Limited .Reg No 1993/001022/06 <br /></span></div><div align='left'><span style=''>1st Floor, Ridgeside Campus, 2 Ncondo Drive, Umhlanga Rocks, 4320 ; PO Box 149175, East End, 4018. <br /></span></div><div align='left'><span style=''>Tel 0860 263 543 Fax 0860 065 437 Website www.nedgrouplife.co.za. <br /></span></div></div>
<div class='div_line_220'></div>
<div class='div_text70'><span style='font: 7pt "Arial";color:#000000;text-decoration:none;'>Page 2 of 2 <br /></span></div>
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